Catheter Ablation for Tachyarrhythmias in Left Ventricular Assist Device Recipients: Clinical Significance and Technical Tips

Abstract

The demand for durable left ventricular assist devices (LVADs) has been increasing worldwide in tandem with the rising population of advanced heart failure patients. Especially in cases of destination therapy, instead of bridges to transplantation, LVADs require a lifelong commitment. With the increase in follow-up periods after implantation and given the lack of donor hearts, the need for managing concomitant tachyarrhythmias has arisen. Atrial and ventricular arrhythmias are documented in approximately 20% to 50% of LVAD recipients during long-term device support, according to previous registries. Atrial arrhythmias, primarily atrial fibrillation, generally exhibit good hemodynamic tolerance; therefore, catheter ablation cannot be easily recommended due to the risk of a residual iatrogenic atrial septal defect that may lead to a right-to-left shunt under durable LVAD supports. The clinical impacts of ventricular arrhythmias, mainly ventricular tachycardia, may vary depending on the time periods following the index implantation. Early occurrence after the operation affects the hospitalization period and mortality; however, the late onset of ventricular tachycardia causes varying prognostic impacts on a case-by-case basis. In cases of hemodynamic instability, catheter ablation utilizing a trans-septal approach is necessary to stabilize hemodynamics. Nonetheless, in some cases originating from the intramural region or the epicardium, procedural failure may occur with the endocardial ablation. Specialized complications associated with the state of LVAD support should be carefully considered when conducting procedures. In LVAD patients, electrophysiologists, circulatory support specialists, and surgeons should collaborate as an integrated team to address the multifaceted issues related to arrhythmia management.

Ventricular Arrhythmias in Left Ventricular Assist Device Patients—Current Diagnostic and Therapeutic Considerations

“…Given the altered anatomy and continuous blood flow support provided by LVADs, safety is paramount during ablation procedures. Several studies have demonstrated the utility of ICE in visualizing the LVAD inflow cannula, outflow graft, and adjacent structures, enhancing the safety and efficacy of catheter ablation [ 61 , 62 , 63 ]. Intracardiac echo aids in the visualization of potential complications, such as catheter entrapment or interference with LVAD components, minimizing the risk of adverse events [ 61 ].…”

“…Studies evaluating the impact of intracardiac echo on clinical outcomes in VT ablation in LVAD patients are limited but encouraging. Improved procedural success rates, reduced recurrence of VT, and enhanced patient safety have been reported in cohorts where ICE was integrated into the ablation strategy [ 61 , 62 , 63 ]. While further research is needed to establish standardized protocols and assess long-term efficacy, current evidence supports the routine use of intracardiac echo in VT ablation for LVAD patients.…”